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psnet.ahrq.gov/node/43830/psn-pdf
February 04, 2015 - A combined teamwork training and work standardisation
intervention in operating theatres: controlled interrupted
time series study.
February 4, 2015
Morgan L, Pickering S, Hadi M, et al. A combined teamwork training and work standardisation intervention
in operating theatres: controlled interrupted time series stu…
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psnet.ahrq.gov/node/47237/psn-pdf
January 01, 2020 - First-year analysis of the Operating Room Black Box
study.
July 25, 2018
Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg.
2020;271(1):122-127. doi:10.1097/SLA.0000000000002863.
https://psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study
An…
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psnet.ahrq.gov/node/34654/psn-pdf
June 16, 2011 - Risk mitigation in large scale systems: lessons from high
reliability organizations.
June 16, 2011
Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-161.
https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
The authors examine high-reliability organizations,…
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psnet.ahrq.gov/node/865527/psn-pdf
April 10, 2024 - Teamwork matters: team situation awareness to build
high-performing healthcare teams, a narrative review.
April 10, 2024
Weller JM, Mahajan R, Fahey-Williams K, et al. Teamwork matters: team situation awareness to build high-
performing healthcare teams, a narrative review. Br J Anaesth. 2024;132(4):771-778.
doi:1…
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psnet.ahrq.gov/node/843521/psn-pdf
February 01, 2023 - How providers can optimize effective and safe scribe use:
a qualitative study.
February 1, 2023
Corby S, Ash JS, Florig ST, et al. How providers can optimize effective and safe scribe use: a qualitative
study. J Gen Intern Med. 2023;38(9):2052-2058. doi:10.1007/s11606-022-07942-2.
https://psnet.ahrq.gov/issue/how-…
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psnet.ahrq.gov/node/40084/psn-pdf
December 15, 2010 - Patterns in nursing home medication errors:
disproportionality analysis as a novel method to identify
quality improvement opportunities.
December 15, 2010
Hansen RA, Cornell PY, Ryan PB, et al. Patterns in nursing home medication errors: disproportionality
analysis as a novel method to identify quality improvement…
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psnet.ahrq.gov/node/855094/psn-pdf
November 08, 2023 - Preferred language and diagnostic errors in the pediatric
emergency department.
November 8, 2023
Lowe JT, Leonard J, Dominguez F, et al. Preferred language and diagnostic errors in the pediatric
emergency department. Diagnosis (Berl). 2024;11(1):49-53. doi:10.1515/dx-2023-0079.
https://psnet.ahrq.gov/issue/preferr…
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psnet.ahrq.gov/node/840167/psn-pdf
November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in
East Kent – the Report of the Independent Investigation.
November 16, 2022
Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022. ISBN:
9781528636759.
https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
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psnet.ahrq.gov/node/34998/psn-pdf
June 22, 2009 - Cause and effect analysis of closed claims in obstetrics
and gynecology.
June 22, 2009
White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and
gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038.
https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-o…
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psnet.ahrq.gov/node/60038/psn-pdf
March 11, 2020 - Errors associated with oxytocin use: a multi-organization
analysis by ISMP and ISMP Canada.
March 11, 2020
ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25(3):1-6.
https://psnet.ahrq.gov/issue/errors-associated-oxytocin-use-multi-organization-analysis-ismp-and-ismp-
canada
Errors in IV …
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psnet.ahrq.gov/node/46425/psn-pdf
September 13, 2017 - Optimizing Crisis Resource Management to Improve
Patient Safety and Team Performance--A Handbook for
Acute Care Health Professionals.
September 13, 2017
Brindley P, Cardinal P, eds. Ottawa, ON, Canada: Royal College of Physicians and Surgeons of Canada;
2017. ISBN: 9781926588414.
https://psnet.ahrq.gov/issue/opti…
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psnet.ahrq.gov/node/42837/psn-pdf
January 08, 2014 - What are the safety risks for patients undergoing
treatment by multiple specialties: a retrospective patient
record review study.
January 8, 2014
Baines RJ, de Bruijne M, Langelaan M, et al. What are the safety risks for patients undergoing treatment by
multiple specialties: a retrospective patient record review s…
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psnet.ahrq.gov/node/40958/psn-pdf
January 19, 2012 - Do older patients' perceptions of safety highlight barriers
that could make their care safer during organisational
care transfers?
January 19, 2012
Scott J, Dawson P, Jones D. Do older patients' perceptions of safety highlight barriers that could make their
care safer during organisational care transfers? BMJ Qual…
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psnet.ahrq.gov/node/47697/psn-pdf
April 03, 2019 - Engineering a foundation for partnership to improve
medication safety during care transitions.
April 3, 2019
Xiao Y, Abebe E, Gurses AP. Engineering a Foundation for Partnership to Improve Medication Safety
during Care Transitions. J Patient Saf Risk Manag. 2019;24(1):30-36. doi:10.1177/2516043518821497.
https://p…
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psnet.ahrq.gov/node/44997/psn-pdf
July 21, 2016 - Crew resource management training in the intensive care
unit. A multisite controlled before-after study.
July 21, 2016
Kemper PF, de Bruijne M, van Dyck C, et al. Crew resource management training in the intensive care unit.
A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87. doi:10.1136/bmj…
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psnet.ahrq.gov/node/50401/psn-pdf
October 02, 2019 - Discrepant advanced directives and code status orders: a
preventable medical error.
October 2, 2019
Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A
Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm.3244.
https://psnet.ahrq.gov/issue/discre…
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psnet.ahrq.gov/node/866867/psn-pdf
October 02, 2024 - Report links Georgia's abortion ban to preventable
deaths.
October 2, 2024
Yang J, Surana K. Report links Georgia's abortion ban to preventable deaths. PBS News Hour. 2024.
https://psnet.ahrq.gov/issue/report-links-georgias-abortion-ban-preventable-deaths
Poorly implemented and communicated policy can affect the a…
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psnet.ahrq.gov/node/40657/psn-pdf
August 03, 2011 - Effectiveness and cost of a transitional care program for
heart failure: a prospective study with concurrent
controls.
August 3, 2011
Stauffer BD, Fullerton C, Fleming N, et al. Effectiveness and cost of a transitional care program for heart
failure: a prospective study with concurrent controls. Arch Intern Med. 2…
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psnet.ahrq.gov/node/47898/psn-pdf
January 01, 2020 - Capturing patients' perspectives on medication safety:
the development of a patient-centered medication safety
framework.
May 8, 2019
Giles SJ, Lewis PJ, Phipps D, et al. Capturing Patients' Perspectives on Medication Safety: The
Development of a Patient-Centered Medication Safety Framework. J Patient Saf. 2020;16…
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psnet.ahrq.gov/node/47181/psn-pdf
August 22, 2018 - Critical role of the surgeon–anesthesiologist relationship
for patient safety.
August 22, 2018
Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. Anesthesiology.
2018;129(3):402-405. doi:10.1097/ALN.0000000000002324.
https://psnet.ahrq.gov/issue/critical-role-surgeon-anesthes…